EMDR is now accepted as a treatment of choice by numerous mental health departments and trauma organizations.

EMDR has a broad base of published case reports and controlled research that supports it as an empirically validated treatment of trauma and other adverse life experiences. The Department of Defense/Department of Veterans Affairs Practice Guidelines have placed EMDR in the highest category, recommended for all trauma populations at all times. In addition, the International Society for Traumatic Stress Studies current treatment guidelines have designated EMDR as an effective treatment for PTSD (Foa, Keane, Friedman, & Cohen, 2009) as have the Departments of Health of both Northern Ireland and Israel (see below), which have indicated EMDR to be one of only two or three treatments of choice for trauma victims. The American Psychiatric Association Practice Guideline (2004) has stated that SSRI's, CBT, and EMDR are recommended as first-line treatments of trauma. Most recently, the World Health Organization (2013) has stated that trauma-focused CBT and EMDR are the only psychotherapies recommended for children, adolescents, and adults with PTSD. “Like CBT with a trauma focus, EMDR aims to reduce subjective distress and strengthen adaptive cognitions related to the traumatic event. Unlike CBT with a trauma focus, EMDR does not involve (a) detailed descriptions of the event, (b) direct challenging of beliefs, (c) extended exposure, or (d) homework.” (p.1)

See Shapiro (1999, 2001, 2002) for procedures, protocols, theories, and discussion of clinically valid research criteria. See Shapiro (2012) for a comprehensive narrative of cases, and in-session transcripts, and "EMDR for Trauma" in APA Psychotherapy Videotape series. More than twenty randomized studies support EMDR therapy as an effective and efficient treatment of trauma. More than two-dozen randomized studies and a recent meta-analysis (Lee & Cuijpers, 2013) have demonstrated the positive effects of the eye movement component. For discussion of studies investigating the eye movement and other bilateral stimulation, please see Frequently Asked Questions.

Bleich, A., Kotler, M., Kutz, I., & Shalev, A. (2002). A position paper of the (Israeli) National Council for Mental Health: Guidelines for the assessment and professional intervention with terror victims in the hospital and in the community. Jerusalem, Israel.

EMDR is one of three methods recommended for treatment of terror victims.

According to a taskforce of the Clinical Division of the American Psychological Association, the only methods empirically supported (“probably efficacious”) for the treatment of any post-traumatic stress disorder population were EMDR, exposure therapy, and stress inoculation therapy. Note that this evaluation does not cover the last decade of research.

CREST (2003).The management of post traumatic stress disorder in adults. A publication of the Clinical Resource Efficiency Support Team of the Northern Ireland Department of Health, Social Services and Public Safety, Belfast.

EMDR was listed as an effective and empirically supported treatment for PTSD, and was given an AHCPR “A” rating for adult PTSD. This guideline specifically rejected the findings of the previous Institute of Medicine report, which stated that more research was needed to judge EMDR effective for adult PTSD. With regard to the application of EMDR to children, an AHCPR rating of Level B was assigned. Since the time of this publication, two additional randomized studies on EMDR have been completed (see below).

INSERM (2004).Psychotherapy: An evaluation of three approaches. French National Institute of Health and Medical Research, Paris, France.

EMDR and CBT were stated to be the treatments of choice for trauma victims.

National Institute for Clinical Excellence (2005).Post traumatic stress disorder (PTSD): The management of adults and children in primary and secondary care. London: NICE Guidelines.

Trauma-focused CBT and EMDR were stated to be empirically supported treatments for choice for adult PTSD.

Best evidence of efficacy was reported for EMDR, exposure, and stress inoculation

World Health Organization (2013).Guidelines for the management of conditions that are specifically related to stress. Geneva, WHO.

Trauma-focused CBT and EMDR are the only psychotherapies recommended for children, adolescents and adults with PTSD. "Like CBT with a trauma focus, EMDR therapy aims to reduce subjective distress and strengthen adaptive cognitions related to the traumatic event. Unlike CBT with a trauma focus, EMDR does not involve (a) detailed descriptions of the event, (b) direct challenging of beliefs, (c) extended exposure, or (d) homework." (p. 1)

Meta-Analyses

EMDR has been compared to numerous exposure therapy protocols, with and without CT techniques. It should be noted that exposure therapy uses one to two hours of daily homework and EMDR uses none. The most recent meta-analyses are listed here.

EMDR is equivalent to exposure and other cognitive behavioral treatments.

Lee, C.W., & Cuijpers, P. (2013). A meta-analysis of the contribution of eye movements in processing emotional memories. Journal of Behavior Therapy & Experimental Psychiatry, 44, 231-239.The effect size for the additive effect of eye movements in EMDR treatment studies was moderate and significant (Cohen’s d = 0.41). For the second group of laboratory studies the effect size was large and significant (d = 0.74).

“Results indicate efficacy of EMDR when effect sizes are based on comparisons between EMDR and non-established trauma treatment or no-treatment control groups, and incremental efficacy when effect sizes are based on comparisons between EMDR and established (CBT) trauma treatment.”

Twelve sessions of EMDR eliminated post-traumatic stress disorder in 77.7% of the multiply traumatized combat veterans studied. There was 100% retention in the EMDR condition. Effects were maintained at follow-up. This is the only randomized study to provide a full course of treatment with combat veterans. Other studies (e.g., Boudewyns/Devilly/Jensen/Pitman et al./Macklin et al.) evaluated treatment of only one or two memories, which, according to the International Society for Traumatic Stress Studies Practice Guidelines (2000), is inappropriate for multiple-trauma survivors. The VA/DoD Practice Guideline (2004) also indicates these studies (often with only two sessions) offered insufficient treatment doses for veterans.

Thirty-three 6-16-year-old children with a DSM-IV diagnosis of PTSD were randomly assigned to eight weekly EMDR sessions or the WLC group. EMDR was found to be an effective treatment in children with PTSD from various sources and who were suffering from a variety of co-morbid conditions.

EMDR treatment of disturbing life events (small “t” trauma) was compared to active listening, and wait list. EMDR produced significantly lower scores on the Impact of Event Scale (mean reduced from “moderate” to “subclinical”) and a significantly smaller increase on the STAI after memory recall.

EMDR treatment resulted in lower scores (fewer clinical symptoms) on all four of the outcome measures at the three-month follow-up, compared to those in the routine treatment condition. The EMDR group also improved on all standardized measures at 18 months follow up (Edmond & Rubin, 2004, Journal of Child Sexual Abuse).

Edmond, T., Sloan, L., & McCarty, D. (2004). Sexual abuse survivors’ perceptions of the effectiveness of EMDR and eclectic therapy: A mixed-methods study. Research on Social Work Practice, 14, 259-272.

Combination of qualitative and quantitative analyses of treatment outcomes with important implications for future rigorous research. Survivors’ narratives indicate that EMDR produces greater trauma resolution, while within eclectic therapy, survivors more highly value their relationship with their therapist, through whom they learn effective coping strategies.

Employees who had experienced “person-under-train accident or had been assaulted at work were recruited.” Six sessions of EMDR resulted in remission of PTSD in 67% compared to 11% in the wait list control. Significant effects were documented in Global Assessment of Function (GAF) and Hamilton Depression (HAM-D) score. Follow-up: Högberg, G. et al. (2008). Treatment of post-traumatic stress disorder with eye movement desensitization and reprocessing: Outcome is stable in 35-month follow-up. Psychiatry Research. 159, 101-108.

Both EMDR and prolonged exposure produced a significant reduction in PTSD and depression symptoms. This is the only research comparing EMDR and exposure therapy that equalized homework. The study found that 70% of EMDR participants achieved a good outcome in three active treatment sessions, compared to 29% of persons in the prolonged exposure condition. EMDR also had fewer dropouts.

In this NIMH funded study both treatments were effective: “An interesting potential clinical implication is that EMDR seemed to do equally well in the main despite less exposure and no homework. It will be important for future research to explore these issues.”

Seminal study appeared the same year as first controlled studies of CBT treatments. Three-month follow-up indicated substantial effects on distress and behavioral reports. Marred by lack of standardized measures and the originator serving as sole therapist.

The only randomized study to show exposure statistically superior to EMDR on two subscales (out of 10). This study used therapist assisted “in vivo” exposure, where the therapist takes the person to previously avoided areas, in addition to imaginal exposure and one hour of daily homework (@ 50 hours). The EMDR group used only standard sessions and no homework.

All treatments led to significant decreases in PTSD symptoms for subjects in the treatment groups as compared to those on a waiting list, with a greater reduction in the EMDR group, particularly with respect to intrusive symptoms. In the 2-3 weeks of the study, 40-60 additional minutes of daily homework were part of the treatment in the other two conditions.

EMDR was superior to both control conditions in the amelioration of both PTSD symptoms and depression. Upon termination of therapy, the EMDR group continued to improve while the Fluoxetine participants again became symptomatic.

Twenty-six children (average age 10.4 years) with behavioral problems were randomly assigned to receive either 4 sessions of EMDR or CBT. Both were found to have significant positive effects on behavioral and self-esteem problems, with the EMDR group showing significantly larger changes in target behaviors.

A comprehensive group intervention with 124 children, who experienced disaster related trauma during a massive flood utilizing a one session group protocol. Significant differences were obtained and maintained at 3-month follow up.

This study found CBT superior to EMDR. The research is marred by higher expectations in the CBT condition: Treatment was delivered in both conditions by the developer of the CBT protocol.

Fernandez, I. (2007). EMDR as treatment of post-traumatic reactions: A field study on child victims of an earthquake. Educational and Child Psychology. Special Issue: Therapy, 24, 65-72.

This field study explores the effectiveness of EMDR and the level of post-traumatic reactions in a post-emergency context on 22 children victims of an earthquake. The results show that EMDR contributed to the reduction or remission of PTSD symptoms and facilitated the processing of the traumatic experience

A group intervention of EMDR was provided to 236 schoolchildren exhibiting PTSD symptoms 30 days post-incident. At four-month follow up, teachers reported that all but two children evinced a return to normal functioning after treatment.

A study of Hurricane Andrew survivors found significant differences on the Impact of Event Scale and subjective distress in a comparison of EMDR and non-treatment condition.

Hensel, T. (2009). EMDR with children and adolescents after single-incident trauma an intervention study. Journal of EMDR Practice and Research, 3, 2-9.

36 children and adolescents ranging in age from 1 year 9 months to 18 years 1 month were assessed at intake, post-waitlist/pretreatment, and at follow up. EMDR treatment resulted in significant improvement, demonstrating that children younger than 4 years of age showed the same benefit as the school-age children.

A study of 200 children treated with a group protocol after a flood in Mexico indicates that one session of treatment reduced trauma symptoms from the severe range to low (subclinical) levels of distress. Data from successful treatment at other disaster sites are also reported.

Data reported on a representative sample of 1500 earthquake victims indicated that five sessions of EMDR successfully eliminated PTSD in 92.7% of those treated, with a reduction of symptoms in the remaining participants.

In this delayed treatment comparison, over half of the participants moved from clinical to normal levels on the Impact of Events Scale, and all but 3 showed at least partial symptom relief on several measures at 1-3 m following a single EMDR session.

One of only two EMDR research studies that evaluated a clinically relevant course of EMDR treatment with combat veterans (e.g., more than one or two memories; see Carlson et al., above). The analysis of an inpatient veterans’ PTSD program (n=100) found EMDR to be superior to biofeedback and relaxation training on seven of eight measures.

Clients made highly significant positive gains on a range of outcome variables, including validated psychometrics and self-report scales. Analyses of the data indicate that EMDR is a useful treatment intervention both in the immediate aftermath of disaster as well as later.

60 railroad employees who had experienced fatal grade crossing accidents were evaluated for workshop outcomes, and for the additive effects of EMDR treatment. Although the workshop was successful, in this setting, the addition of a short session of EMDR (5-40 minutes) led to significantly lower, sub clinical, scores which further decreased at follow up.

Sprang, G. (2001). The use of eye movement desensitization and reprocessing (EMDR) in the treatment of traumatic stress and complicated mourning: Psychological and behavioral outcomes. Research on Social Work Practice, 11, 300-320.

In a multi-site study, EMDR significantly reduced symptoms more often than the CBT treatment on behavioral measures, and on four of five psychosocial measures. EMDR was more efficient, inducing change at an earlier stage and requiring fewer sessions. Positive recall of the deceased was significantly greater post treatment in the EMDR condition.

Zaghrout-Hodali, M., Alissa, F. & Dodgson, P.W. (2008). Building resilience and dismantling fear: EMDR group protocol with children in an area of ongoing trauma. Journal of EMDR Practice and Research, 2, 106-113.

Results indicate that the EMDR approach can be effective in a group setting, and in an acute situation, both in reducing symptoms of posttraumatic and peritraumatic stress and in “inoculation” or building resilience in a setting of ongoing conflict and trauma.

Adaptive Information Processing and EMDR Procedures

The Adaptive Information Processing model (Shapiro, 2001, 2002, 2007) is used to explain EMDR's clinical effects and guide clinical practice. This model is not linked to any specific neurobiological mechanism since the field of neurobiology is as yet unable to determine this in any form of psychotherapy (nor of most medications). This section includes literature to provide an overview of the model and procedures, as well as selected research and case reports that demonstrate the predictive value of the model in the treatment of life experiences that appear to underlie a variety of clinical complaints.

Processing of etiological disturbing memories, triggers and templates resulted in complete remission of Major Depressive Disorder in two teenagers. Treatment duration was 3-7 sessions and effects were maintained at follow-up.

20 EMDR sessions that focused on reprocessing the memories seemingly at the foundation of the pathology, along with triggers and future templates resulted in a complete remission of BPD, including symptoms of affect dysregulation, as measured on the Inventory of Altered Self Capacities.

Four subjects were evaluated using a single case design with multiple baselines Results indicate that subsequent to targeting the experiential contributors, at posttreatment and at 2 months follow-up, all four participants no longer presented with GAD diagnosis.

EMDR treatment of four consecutive cases of ORS whose pathological symptoms had endured for 8–48 years resulted in a complete resolution of symptoms in all four cases, which was maintained at follow-up.

Supports a basic tenet of the Adaptive Information Processing model that “Life events can generate at least as many PTSD symptoms as traumatic events.” In a survey of 832 people, “For events from the past 30 years the PTSD scores were higher after life events than after traumatic event.”

Reviews common errors and misperceptions of the procedures, research, and theory.

Raboni, M.R., Tufik, S., and Suchecki, D. (2006). Treatment of PTSD by eye movement desensitization and reprocessing improves sleep quality, quality of life and perception of stress. Annals of the New York Academy of Science, 1071, 508-513.

Specifically citing the hypothesis that EMDR induces processing effects similar to REM sleep (see also Stickgold, 2002, 2008), polysomnograms indicated a change in sleep patterns post treatment, and improvement on all measures including anxiety, depression, and quality of life after a mean of five sessions.

As predicted by the Adaptive Information Processing model the EMDR treatment of the molesters’ own childhood victimization resulted in a decrease in deviant arousal as measured by the plethysmograph, a decrease in sexual thoughts, and increased victim empathy. Effects maintained at one year follow up.

“Since September 2006, over 725 service-members from the global war on terrorism have survived combat-related traumatic amputations that often result in phantom limb pain (PLP) syndrome. . . . Four sessions of Eye Movement Desensitization and Reprocessing (EMDR) led to elimination of PLP, and a significant reduction in PTSD, depression, and phantom limb tingling sensations.”

As predicted by the Adaptive Information Processing model the EMDR treatment of the event involving the limb loss, and the stored memories of the pain sensations, resulted a decrease or elimination of the phantom limb pain which maintained at 1 year follow up.

EMDR is an eight-phase psychotherapy with standardized procedures and protocols that are all believed to contribute to therapeutic effect. This text provides description and clinical transcripts and an elucidation of the guiding Adaptive Information Processing model.

Overview of EMDR treatment based upon an Adaptive Information Processing case conceptualization. Early life experiences are viewed as the basis of pathology and used as targets for processing. The three-pronged protocol includes processing of the past events that have set the foundation for the pathology, the current triggers, and templates for appropriate future functioning to address skill and developmental deficits.

Overview of Adaptive Information Processing model, including how the principles are reflected in the procedures, phases and clinical applications of EMDR. Comprehensive worksheets for client assessment, case formulation, and treatment as well as scripts for various procedures.

Using an Adaptive Information Processing conceptualization a wide range of family problems and impasses can be addressed through the integration of EMDR and family therapy techniques. Family therapy models are also useful for identifying the targets in need of processing for those engaged in individual therapy.

This article provides a brief overview of some of the major precepts of the Adaptive Information Processing model, a comparison and contrast to extinction-based information processing models and treatment and a discussion of a variety of mechanisms of action.

The study evaluated the impact of EMDR treatment on bias mechanisms in depressed subjects in regard to negative emotional valence evaluation. “The results indicated that it generated important cognitive emotional changes in such mechanisms.” Priming tests indicated changes in the negative valence evaluation of emotional information indicative of recovery with decreased reaction times in the neutral and positive stimuli processing.”

“Five consecutive cases of phantom limb pain were treated with EMDR. Four of the five clients completed the prescribed treatment and reported that pain was completely eliminated, or reduced to a negligible level. . . The standard EMDR treatment protocol was used to target the accident that caused the amputation, and other related events.”

Mechanism of Action

EMDR contains many procedures and elements that contribute to treatment effects. While the methodology used in EMDR has been extensively validated (see above), questions still remain regarding mechanism of action. However, since EMDR achieves clinical effects without the need for homework, or the prolonged focus used in exposure therapies, attention has been paid to the possible neurobiological processes that might be evoked. Although the eye movements (and other dual attention stimulation) comprise one only one procedural element, this element has come under greatest scrutiny.Randomized controlled studies evaluating mechanism of action of the eye movement component follow this section.

Changes in heart rate, skin conductance and LF/HF-ratio, finger temperature, breathing frequency, carbon dioxide and oxygen levels were documented during the eye movement condition. It was concluded the “eye movements during EMDR activate cholinergic and inhibit sympathetic systems. The reactivity has similarities with the pattern during REM sleep.”

This study tested whether the content of participants’ responses during EMDR is similar to that thought to be effective for traditional exposure treatments (reliving), or is more consistent with distancing which would be expected given Shapiro’s proposal of dual focus of attention. Greatest improvement on a measure of PTSD symptoms occurred when the participant processed the trauma in a more detached manner, which indicates the underlying mechanisms of EMDR and exposure therapy are different.

One of a variety of articles positing an orienting response as a contributing element (see Shapiro, 2001 for comprehensive examination of theories and suggested research parameters). This theory has received controlled research support (Barrowcliff et al., 2003, 2004).

“Specifically, the EM manipulation used in the present study, reported previously to facilitate episodic memory, resulted in decreased interhemispheric EEG coherence in anterior prefrontal cortex. Because the gamma band includes the 40 Hz wave that may indicate the active binding of information during the consolidation of long-term memory storage (e.g., Cahn and Polich, 2006), it is particularly notable that the changes in coherence we found are in this band. With regard to PTSD symptoms, it may be that by changing interhemispheric coherence in frontal areas, the EMs used in EMDR foster consolidation of traumatic memories, thereby decreasing the memory intrusions found in this disorder.”

This study was designed as primarily a process report to compare EMDR and exposure therapy. A different recovery pattern was observed with the EMDR group demonstrating a more rapid decline in self-reported distress.

The psycho-physiological correlates of EMDR were investigated during treatment sessions of trauma patients. The initiation of the eye movements sets resulted in immediate changes that indicated a pronounced de-arousal.

Twenty-one patients with single-event PTSD (average IES: 49.5) received three consecutive sessions of EMDR with three different types of auditory and kinesthetic stimulation. All were clinically useful. However, alternating stimulation appeared to confer an additional benefit to the EMDR procedure.

The article explores the differences between memory reconsolidation and extinction. This new area of investigation is worthy of additional attention. Reconsolidation may prove to be the underlying mechanism of EMDR, as opposed to extinction caused by prolonged exposure therapies. “Memory reconsolidation after retrieval may be used to update or integrate new information into long-term memories . . . Brief exposure … seems to trigger a second wave of memory consolidation (reconsolidation), whereas prolonged exposure . . leads to the formation of a new memory that competes with the original memory (extinction).”

Study involving biofeedback equipment has supported the hypothesis that the parasympathetic system is activated by finding that eye movements appeared to cause a compelled relaxation response. More rigorous research with trauma populations is needed.

Randomized Studies of Hypotheses Regarding Eye Movements

A number of International Practice Guideline committees have reported that the clinical component analyses reviewed by Davidson & Parker (2001) are not well designed (International Society for Traumatic Stress Studies/ISTSS (2000); DoD/DVA). Davidson & Parker note that there is a trend toward significance for eye movements when the studies conducted with clinical populations are examined separately. Unfortunately even these studies are methodologically flawed. As noted in the ISTSS guidelines (Chemtob et al., 2000), since these clinical populations received insufficient treatment doses to obtain substantial main effects, they are inappropriate for component analyses. However, as noted in the DoD/DVA (2004) guidelines, numerous memory researchers have evaluated the eye movements used in EMDR. These studies have found a direct effect on emotional arousal, imagery vividness, attentional flexibility, and memory association. In addition, a new study has examined the hypothesis that the eye movements cause a “distancing effect” (Lee & Drummond, 2008) and is listed below as well.

Three studies were done with cumulatively support a working-memory account of the eye movement benefits in which the central executive is taxed when a person performs a distractor task while attempting to hold a memory in mind.

Tested the orienting response theory related to REM-type mechanisms. Indicated that the eye movement condition was correlated with increased attentional flexibility. Eye movements were superior to control conditions.

“There was no significant effect of therapist’s instruction on the outcome measures. There was a significant reduction in distress for eye movement at post-treatment and at follow-up.. . . The results were consistent with other evidence that the mechanism of change in EMDR is not the same as traditional exposure.”

In two experiments participants focused on negative memories while engaging in three dual-attention eye movement tasks of increasing complexity. Results support a working memory explanation for the effects of eye movement dual-attention tasks on autobiographical memory.

Bilateral saccadic eye movements were compared to vertical and no eye movements. “It was found that bilateral eye movements increased true memory for the event, increased recollection, and decreased the magnitude of the misinformation effect.” This study supports hypotheses regarding effects of interhemispheric activation and episodic memory.

All psychophysiological studies have indicated significant de-arousal. All neurobiological studies have indicated significant effects, including changes in cortical, and limbic activation patterns, and increase in hippocampal volume.

Combat Veteran Treatment

As noted in the American Psychiatric Association Practice Guidelines (2004, p.18), in EMDR “traumatic material need not be verbalized; instead, patients are directed to think about their traumatic experiences without having to discuss them.” Given the reluctance of many combat veterans to divulge the details of their experience, this factor is relevant to willingness to initiate treatment, retention and therapeutic gains. It may be one of the factors responsible for the lower remission and higher dropout rate noted in this population when CBT techniques are used.

As described previously, Carlson et al. (1998) reported that after twelve treatment sessions, 77.7% of the combat veterans no longer met criteria for PTSD. There were no dropouts and effects were maintained at 3- and 9-month follow-up. In addition, the Silver et al., (1995) analysis of an inpatient veterans’ PTSD program (n = 100) found EMDR to be superior to biofeedback and relaxation training on seven of eight measures. All other randomized studies of veterans have used insufficient treatment doses to assess PTSD outcomes (e.g., two sessions; see ISTSS, 2000; DVA/DoD, 2005). Sufficient treatment time must be used for multiply traumatized veterans (e.g., see below: Russell et al., 2007). However, in a process analysis, Rogers et al. (1999) compared one session of EMDR and exposure therapy with inpatient veterans, and a different recovery pattern was observed. The EMDR group demonstrated a more rapid decline in self-reported distress (e.g., SUD levels decreased with EMDR and increased with exposure).

As stated in the American Psychiatric Practice Guidelines (2004, p. 36), if viewed as an exposure therapy, “EMDR employs techniques that may give the patient more control over the exposure experience (since EMDR is less reliant on a verbal account) and provides techniques to regulate anxiety in the apprehensive circumstance of exposure treatment. Consequently, it may prove advantageous for patients who cannot tolerate prolonged exposure as well as for patients who have difficulty verbalizing their traumatic experiences. Comparisons of EMDR with other treatments in larger samples are needed to clarify such differences.”

Such research is highly recommended. In addition, since EMDR utilizes no homework to achieve its effects it may be particularly suited for front line alleviation of symptoms (see Russell, 2006; Wesson & Gould, 2009). Further, the prevalent somatic and chronic pain problems experienced by combat veterans indicate the need for additional research based upon the reports of Russell (2008), Schneider et al., (2007, 2008) and Wilensky (2007), which demonstrate EMDR’s capacity to successfully treat phantom limb pain (see also Ray & Zbik, 2001). The ability of EMDR to simultaneously address PTSD, depression, and pain can have distinct benefits for DVA/DoD treatment.

The following contain clinically relevant information for the treatment of veterans, including therapy parameters.